Nursing Care in Metabolic Patients Treated with Continuous Renal Replacement Therapy (Crrt)

NURSING CARE IN METABOLIC PATIENTS TREATED WITH CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT). Bandinu V, Avari N, Iacoella E, Lozzi P, Moretti MC, Pia C, Tancredi A.

At Bambino Gesù Hospital, CRRT nursing is provided through an open system involving Dialysis, PICU and NICU nurses. Dialysis nurses are also involved in clinical decision-making and CRRT related therapy adjustments. When CRRT is applied on patients with metabolic decompensation, nursing poses a certain number of peculiar problems. Metabolic decompensation is mainly induced by hyperammonemia (urea cycle defects or organic acidurias) or by accumulation of aminoacids into CNS cells (leucinosis). Both entities cause neurotoxicity, long term neurological impairment and death. Thus, a quick onset of CRRT is required in patients not responding to medical treatment. Through the years, two groups of issues have been identified. Issues concerning human resources, organization and staffing → consequences:  CRRT onset rapidity: the nurse on call is alerted from the NICU together with the nephrologist and the metabolism expert → time needed to monitor set up and priming must be anticipated during medical treatment phase (some monitors require longer preparation, i.e.: Prismaflex™ testing phase longer than Aquarius™)  short duration: all described patients tend to resolve decompensation after 48 hours of CRRT (2-47hours in our series) → useful to know for nurse scheduling  usually neonates: most difficult patients → skilled nurses and adequate staffing required. Issues concerning CRRT management → consequences:  High dialysate flow required (up to 5 l/hour to maximize small molecules removal) → supply large number of bags. Increased workload.  CRRT-induced alcalosis in hyperammonemia may be deleterious → frequent plasma bicarbonate control. Increased workload.  TPN induced hyperglycemia may be deleterious → frequent plasma glucose control. Increased workload.  Ammonium, aminoacids plasma, dialysate and urine levels control → increased workload

In conclusion: specific problems arise in CRRT of metabolic children. The consequences of these problems must be considered in advance in order to improve nursing, organization and management.

Pediatric Dialysis Unit Dept. Of Nephrology and Urology “Bambino Gesù” Children’s Hospital and Research Institute Piazza S. Onofrio, 4 00165 ROME, Italy Email: [email protected] [email protected]